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SAN JOAQUIN LOCAL T.MALTH DISTRICT
<br /> FOR OFFICE USE:, 1601 E. Hazelton",,4 :-,iiStockton, Calif.
<br /> 2-09)N 466
<br /> Telo_phone.:,',,..( '1 ;.-6781
<br /> .
<br /> APPLICATION FOR WELL GON9tRUCTIOW.:0R PUMP PERMIT Permit
<br /> THIS PERMIT-,-EXP-I-RES-.?-I�'iY.,EAR.-j.rROiM-.,,DATEj'ISeSUED',:)j� i-i 10D.a:t0_`'I9'6ue 'L-
<br /> ac sn J
<br /> A ii QW-- s by---,modes to �'thet��S-an�Joa-quin"i".,.Lzo4&1 R&,al'th b=,constr-uclf
<br /> pp t i'-�hi�re - . . , . 9.
<br /> and/or install ,the work herein described. Thi§F-,upp1,i c at1onisc'made I-in--,T compliance- wi th•,San-,'Joaquin
<br /> County.a,prdinaiice-)Nor,1-862;S..a:ftd.-,rth&�;Rurlebacid-,='Re.gul,aSo"
<br /> ,ti, - of:-the, an"Joaquin�_`
<br /> T
<br /> JOB ADDRESS/LOCATION CENSUS,,,TRACV0
<br /> .v,,'r�-fiqV:ro qfT!.a;,F-Lm -f.) VJr��*qo,�) .q -illl ii
<br /> W
<br /> Owner.!!§sNiirrW�l 'lo P la
<br /> 1300 '.City
<br /> Address Al
<br /> Contractorts Name License # ZZ Phone 33
<br /> TYPE OF WORK . (Check) : NEW WELD JV DEEPEN RECONDITION DESTRUCTION -7
<br /> MAT ON -0- /7--/-PUMP REPLACEMENT 17
<br /> PUIQ -INST I PUMP REPAIR
<br /> ....Other,
<br /> DISTANCE TO NEAREST: 'SEPTIC' TANK" SEWER LINES PIT PRIVY
<br /> ;SEWAGE- DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER
<br /> INTENDED- USE,'' TYPE -OF WELL 'CONSTRUCTION SPECIFIUTIONS
<br /> Industiial. A- Cable Tool Dia. of Well Excavation
<br /> Domes tic/private Drilled Dia. 'of Well Casing
<br /> Domestic/public DriVen Gauge of Casing
<br /> Irrigation _.Gravel Pack Depth of: Grout Seal
<br /> Other i Rotary Type of Grout
<br /> Other Othei Information
<br /> PUMP INSTALLAraTION! '-Coh dtor
<br /> :..Type e 6f Pump ' H.P.,
<br /> p
<br /> PUMP REPLACEMENT: Stat0_ Work Done
<br /> PUMP REPAIR:_ /.State -Work Dg e
<br /> n
<br /> .—
<br /> ,DESTRUCTION OF WELL:., Well Diameter Approximate Depth.
<br /> Describe Material and Procedure
<br /> I h6reby agree to comply with, all laws and regulations of the San- Joaquin Local Health District
<br /> andithe State of California pertaining to or regulating well construction. Within FIFTEEN DAYiS
<br /> af t6-k'-i--oinp le tion-of" my 46ik-ori'a -iie-w—�Fe_Ir,—1-411:1, f urniiih-theSanJoaq.u.in 'Lo-cal:_Hearth Di'-;ri6t a
<br /> WELL DRILLERS REPORT of the well and notify them before putting
<br /> \the well!Yii,�use. The -above
<br /> information is true t6 the best:
<br /> , of my,knowledge and belief.,
<br /> SIGNED : TITLE-
<br /> 7 7 (DRAW PLOT PLAN ON REVERSE ST
<br /> FOR DEPARTMENT USE ONLY
<br /> PHASE I
<br /> APPLICATION ACCEPTED BY DATE
<br /> ADDITIONAL COMMENTS:
<br /> PHASE 11 GROUT INSPECTION- s PHASE III/FINAL INSPECTION .
<br /> �L-
<br /> INSPECTION By DATE INSPECTION BY AQ�
<br /> DATE
<br /> 3—
<br /> CALL FOR A GROUT: IN8PEi 3TION PRIOR TO GROUTING AND FINAL INSPECTION.___
<br /> 4/72 1M
<br />
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